The polished and comprehensive January JADA article by Drs. Amid Ismail and James Bader, "Evidence-Based Dentistry in Clinical Practice," tirelessly reiterates the evidence-based dentistry, or EBD, mantra: the definitions, the hierarchy of evidence, the systematic review process, clinical decision-making and the step-by-step modus operandi that promises to "help practitioners provide the best care to patients."
The authors quote the American Dental Association’s definition of EBD,1 which unmistakably identifies the significance of the "patient’s treatment needs and preferences," and then presents three elegant models for clinical decision-making that conspicuously omit any mention of the patient in the decision-making process.
Unquestionably, the patient’s preferences ensure the involvement of the patient in joint decision-making within the care process, but should we be surprised that informed shared decision-making continues to be marginalized?
Where are we failing? Is the clinician or the patient at fault? What is the significance of the patient’s treatment needs and preferences? Should our patients have the right of access to the "evidence" of what works, doesn’t work or what works best? Is it important that they are offered evidence and choices to satisfy their expressed preferences, and not just the normative clinician-determined needs?
Moreover, are our patients interested in, let alone capable of, evaluating the evidence jointly? Interestingly enough, not all patients wish to be involved in, or are even capable of involvement in, decision-making.
Finally, some patients’ decisions may be based on subtle differences in personal values and utility. These factors may affect how much of a trade-off in "side effects" patients are prepared to make against clinician-defined advantages of certain treatments.
So, should we accept that this "knowledge is both a tool and commodity that can be used to improve decisions made by dentists every day," but also knowledge that possibly excludes joint decisions made with the patient? Or should we choose the other "benefit of this practice model ... that it protects the dentist from legal liability?"
In a recent article,2 we postulated the emergence of a new species of Homo sapiens, the elusive evidence-informed patient Homo evidensis. But so far there have been remarkably few sightings.
We wrote in an October 2003 JADA letter to the editor that existing perceptions of EBD "strengthen the supposition that the full message is not well understood." It is apparent that the application of EBD to the dental sector still poses a number of challenges, the most testing of which may be the "re-engineering" of the profession’s attitudes toward the involvement of patients in decision-making. Decision-making can no longer be the sole prerogative of the clinician. Acquisition of the necessary skills by the clinician to enable him or her to adapt to a patient-preferred level of involvement in decision-making is vital for the effective practice of EBD.
Evidence will emerge as "king," our patient will move from a passive to an active role and will, like any other "customer," demand decision-making information based on all the evidence available. Clearly, the future of EBD will be part of a challenge of individualizing care based on best evidence, clinical judgment and, not least of all, the patient’s treatment needs and preferences.
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